Improving glycemic control among underserved patients with insulin-treated type 2 diabetes through nurse-led, app-based behavioral intervention

通过护士主导、基于应用程序的行为干预，改善接受胰岛素治疗的 2 型糖尿病患者的血糖控制

• 批准号: 10591769
• 负责人: Helen Nai-Chi Chen
• 金额: $ 16.24万
• 依托单位: INDIANA UNIV-PURDUE UNIV AT INDIANAPOLIS
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-20 至 2025-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10591769
• 关键词: Address; Area; Award; Behavior; Behavior Therapy; Blood Glucose; Care given by nurses; Caring; Cellular Phone; Characteristics; Chronic Disease; Clinic; Clinical; Collaborations; Complex; Coping Skills; Cultural Sensitivity; Data; Development; Diabetes Mellitus; Diet; Disease; Disease Management; Documentation; Education; Educational Materials; Educational Technology; Electronic Health Record; Electronics; Environment; Evaluation; Event; Evidence based intervention; Exercise; Face; Failure; Feedback; Focus Groups; Funding; Future; Goals; Health Services Accessibility; Health system; Indiana; Informatics; Insulin; Intervention; Manuals; Mentors; Methods; Modeling; Neighborhoods; Non-Insulin-Dependent Diabetes Mellitus; Nurses; Outcome; Participant; Patient Education; Patients; Pharmaceutical Preparations; Phase; Pilot Projects; Population; Population Characteristics; Practice Guidelines; Problem Solving; Procedures; Protocols documentation; Public Health Informatics; Qualitative Methods; Recommendation; Reduce health disparities; Registries; Reporting; Research; Resources; Secure; Self Management; Technology; Therapeutic; Time; Training; Universities; Visit; Work; Writing; barrier to care; biomedical informatics; career; data exchange; design; diabetes educator; effectiveness evaluation; effectiveness testing; experience; family management; food insecurity; glycemic control; health care quality; health disparity; health information technology; health management; high risk; implementation science; implementation strategy; improved; improved outcome; low health literacy; low socioeconomic status; member; minority health; minority health disparity; operation; patient engagement; patient outreach; patient portal; patient-clinician communication; pilot test; population health; pragmatic trial; programs; recruit; remote monitoring; remote patient monitoring; social determinants; technology validation; therapy development; tool; transmission process; virtual

“Therapeutic inertia,” defined as a lack of timely adjustment to therapy when a patient’s treatment goals are not met, is a major cause of poor outcomes in Type 2 Diabetes (T2D). This is especially true for low socioeconomic status (low-SES) populations, who often face barriers to effective disease self-management at three levels: (1) patient (e.g., limited resources, low health literacy, and limited access to care); (2) clinician (e.g., lack of time and/or poor cultural sensitivity); and (3) health system (e.g., poor or absent decision support and effective patient panel management). One way to address the complex challenges of chronic disease management at these three levels is with multi-level health information technology (HIT)-supported behavioral interventions. Such interventions combine changes to clinical workflows and self-management support to help patients track diabetes electronically, transmit data to clinicians, and receive feedback for adjusting treatment. Currently, minimal data exist to inform optimal design, implementation, and use of such multi-level behavioral interventions, particularly for low-SES populations. My career goal is to establish an independently funded research program that helps decrease health disparities using technologies that support effective long-term self-management and improve outcomes. In this project, I propose a 5-year training and research plan for a multi-level app-based intervention to improve outcomes for T2D in low-SES populations. I will develop and pilot-test a nurse-led, app-based behavioral intervention consisting of three evidence-based interventions: (1) education on A1C results and goal setting via MyChart, the patient portal in the Epic electronic health record; (2) a problem-solving action plan developed by clinicians in collaboration with their patients; and (3) remote monitoring via OnTrack, a top-rated diabetes app, to analyze blood glucose and identify the need to adjust treatment. Training in population health informatics, HIT implementation science, health disparities, and pragmatic trials will not only allow me to complete the proposed project, but will set the stage for expanding the concept to other diseases and clinical use cases. Indiana University and the Regenstrief Institute, an informatics powerhouse, plus a strong team of mentors in biomedical informatics, HIT implementation, health disparity, and qualitative methods, provide an exceptional scientific environment. The proposed work includes: (1) time-to-event analysis to understand population characteristics associated with persistent therapeutic inertia, used to guide intervention development and tailoring [Aim 1]; (2) input from diabetes care team to adapt the intervention and implementation strategies to the clinical operations level [Aim 2]; (3) a focus group study with low-SES patients to help tailor the intervention [Aim 3]; and (4) a pilot study at two clinics (n=60, 30 patients per clinic) to assess the feasibility of the intervention for low-SES patients with insulin-treated T2D [Aim 4]. The project will support a future R01 application for a pragmatic trial to assess the effectiveness of a multi-level app-based behavioral intervention for low-SES populations with T2D.

“治疗惰性”，定义为当患者的治疗目标未达到时，缺乏及时调整治疗的能力。 是 2 型糖尿病 (T2D) 预后不良的主要原因，对于低血糖尤其如此。 失业状态（低SES）人群，他们经常面临有效疾病自我管理的障碍 三个层面：(1) 患者（例如，资源有限、健康素养低、获得护理的机会有限）；(2) 临床医生 （例如，缺乏时间和/或文化敏感性差）；以及 (3) 卫生系统（例如，决策支持不佳或缺乏）； 和有效的患者小组管理）是解决慢性病复杂挑战的一种方法。 这三个层面的管理是通过多层次的健康信息技术（HIT）支持的行为 此类干预措施结合了临床工作流程的改变和自我管理支持来提供帮助。 患者以电子方式跟踪糖尿病，将数据传输给教区居民，并接收调整治疗的反馈。 目前，只有很少的数据可以为此类多层次行为的设计、实施和使用提供最佳信息。 干预措施，特别是针对社会经济地位低的人群。我的职业目标是建立一个独立资助的机构。 使用支持有效长期的技术帮助减少健康差距的研究计划 在这个项目中，我提出了一个为期 5 年的培训和研究计划。 我将开发和改进基于应用程序的多层次干预措施，以改善低社会经济地位人群的 T2D 治疗结果。 试点测试由护士主导、基于应用程序的行为干预措施，其中包括三种基于证据的干预措施：(1) 通过 MyChart（Epic 电子健康记录中的患者门户）进行 A1C 结果和目标设定的教育； (2) 弟子与患者合作制定的解决问题的行动计划；以及 (3) 远程； 通过顶级糖尿病应用程序 OnTrack 进行监测，分析血糖并确定是否需要调整 人口健康信息学、HIT 科学实施、健康差异等方面的培训。 务实的试验不仅能让我完成拟议的项目，而且将为扩大 其他疾病和临床用例的概念。 信息学强国，加上生物医学信息学、HIT实施、健康方面强大的导师团队 差异和定性方法提供了一个特殊的科学环境。拟议的工作包括： (1) 事件发生时间分析，以了解与持续治疗相关的人群特征 惯性，用于指导干预措施的制定和调整[目标 1](2) 适应糖尿病护理团队的投入； 临床操作层面的干预实施和策略[目标2]（3）焦点小组研究； 与低 SES 患者一起帮助调整干预措施 [目标 3]；以及 (4) 在两个诊所进行试点研究（n=60、30） 每个诊所的患者）来评估对接受胰岛素治疗的低SES患者进行干预的可行性 T2D [目标 4]。该项目将支持未来的 R01 申请进行务实试验，以评估有效性。 针对低 SES 人群的 T2D 进行基于应用程序的多层次行为干预。